Professional Documents
Culture Documents
Briefing paper 2
May 2020
WCPT briefing papers
WCPT briefing papers inform WCPT member organisations and others about key issues that affect the
physical therapy profession.
Acknowledgement
This paper has been produced with the helpful contributions from the following:
Tracy Bury, Nicola Clague-Baker, Judy Deutsch, Laura Finucane, Hans Hobbelen, Linzette Morris, Philip
van der Wees, Emma Stokes, and Ruth ten Hove
Introduction
This briefing paper focuses on rehabilitation as it applies to individuals and will also consider the wider
systems issues as they relate to physiotherapy. A later briefing paper will consider the impact of
COVID-19 and rehabilitation in fragile systems and vulnerable communities.
The focus in the paper is on:
people with short-term rehabilitation needs where routine care has been suspended
return to work
service delivery
Key messages
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Post-acute COVID-19 rehabilitation phase
Physiotherapists are vital for rehabilitation as patients transition
from the acute to the post-acute phase.
Patients, their families and carers should not be set adrift from
their rehabilitation services to avoid deterioration and the potential
negative impact on their general physical and mental wellbeing.
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Short term rehabilitation where routine care is suspended
Absence of physiotherapy rehabilitation provision will have long
term consequences leading to increase need and potentially
increased disability.
There is a risk this need will not be met due the immediate impact
on service providers resulting from lockdown restrictions and
changes to funding priorities once restrictions ease.
Occupational rehabilitation
Once lockdown eases return to work will not be straightforward for
some who will have physiotherapy related rehabilitation needs.
Physiotherapists have a key role to play in ensuring fitness to return
to work and advising on adaptive requirements.
The occupational health and safety of physiotherapists also needs
supporting with appropriate personal protective equipment (PPE).
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Service delivery
There will be increased demand for rehabilitation professionals
working in acute and critical care settings, and action is needed to
ensure staffing requirements are met.
Integrated care planning for those individuals with long term needs
will require multi-professional and inter-sectoral cooperation
across settings, including the home environment.
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Context
WCPT is made up of 121 member organisations from five regions and from low, middle and high
resource countries. Hence there is great diversity in the delivery of physiotherapy and rehabilitation
services in the countries/territories of its member organisations.
We note that there are a variety of contexts in which practice takes place as well as a diversity of
health care delivery systems in which physiotherapy is practised globally. Moreover, the trajectory and
impact over time of COVID-19 means that as the epicentre moves, societies and communities will be
affected in different ways.
WCPT is in close contact with its member organisations across all settings and has been collating the
resources generated nationally and the publications emerging via its COVID-19 knowledge hub. It will
continue to provides links to resources to inform practice, drawing on resources from within the
profession and other global organisations.
Early reports highlight that the rehabilitation needs of people with severe COVID-19 exist during the
acute, sub-acute and long-term phases of the disease. Physiotherapists are vital to the rehabilitation
efforts in intensive care units (ICUs), hospital wards, stepdown facilitates and in the community (Pan
American Health Organization, 2020, Thomas et al., 2020). The appropriate deployment of
physiotherapists to reflect the local needs may facilitate early discharge, thus reducing the burden on
scarce hospital beds.
The role of physiotherapists in supporting and empowering individuals to self-manage their
rehabilitation, where appropriate and able, is important at any time and particularly so when access is
restricted or service delivery changed.
WHO and other organisations, such as the European Respiratory Society, are gathering evidence
globally. For example see:
WHO searchable database on global research on COVID-19 updated daily from searches of
bibliographic databases, hand searching, and the addition of other expert-referred scientific
articles
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rehabilitation in the community. They have been developed in a country hit hard by the pandemic and
may be of interest to others, though they may not apply in all settings.
The acute physiotherapy management of patients with COVID-19 has received a focus with the
development of clinical guidelines (Thomas et al., 2020) and papers (Kiekens et al., 2020, Lazzeri et
al., 2020). The guidelines are currently available in 24 languages on the WCPT website to support
acute physiotherapy rehabilitation globally.
Resources such as apps like OnCall buddy and online courses have been developed to support
physiotherapists who have been re-deployed into respiratory practice.
The early and short-term rehabilitation needs of patients recovering from COVID-19 are under
consideration in a guideline being developed by the European Respiratory Society
https://ers.app.box.com/s/npzkvigtl4w3pb0vbsth4y0fxe7ae9z9 This provides access to a live
document that is being update regularly with a guideline anticipated at a later stage. It lists 27
questions about what is not yet known about COVID-19 survivors (as at 3 April 2020), which may be
relevant for rehabilitative interventions.
WCPT’s member organisation in the Netherlands, the Royal Dutch Society for Physiotherapy (KNGF)
has produced a position statement with guidance for COVID-19 related rehabilitation issues, which
has been translated into English. It describes recommendations regarding physiotherapy services, for
patients with confirmed or suspected COVID-19, after hospital discharge or patients who have been ill
at home (Royal Dutch Society for Physiotherapy, 2020).
The British Society of Rehabilitation Medicine has produced recommendations for rehabilitation
services for adults aged 16 years and over in the wake of the COVID-19 pandemic, in particular
addressing the need to support patients with more complex rehabilitation needs (Phillips et al., 2020).
The importance of integrated planning across the care pathway is highlighted.
As noted previously, people with severe COVID-19 have rehabilitation needs beyond the acute phase
(Pan American Health Organization, 2020). The appropriate deployment of physiotherapists across
the care pathway is important for rehabilitation. Optimal recovery from severe cases of COVID-19 will
require the expansion of stepdown facilities that provide rehabilitation. These facilities enable early
discharge from acute settings where bed shortages occur. It is not clear that service planning has
advanced to consider the rehabilitation model that best fits with the population needs beyond
addressing the acute phase.
The World Federation for NeuroRehabilitation has published a series of chapters in response to the
COVID-19 pandemic, the first of which provides guidance on rehabilitation for people with COVID-19.
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A number of emerging clinical perspectives give rise for rehabilitation concerns, namely post-intensive
care syndrome (PICS) (box 1) and post-viral fatigue syndrome (box 2) in patients with COVID-19.
Stam et al have highlighted the need to prepare for the aftershocks of the
pandemic and ongoing rehabilitation needs associated with post-intensive
care syndrome (PICS) and other severe conditions (Stam et al., 2020).
Kiekens et al have described clinical experiences in Northern Italy
indicating relatively long lengths of stay in the ICU units for patients with
COVID-19, with immobilisation in the prone position. They describe
specific problems in the post-acute phase such as severe muscle
weakness, fatigue, joint stiffness, dysphagia, (neuro)psychological
problems and impaired mobility and functioning, highlighting how crucial
physiotherapists are in early and ongoing rehabilitation (Kiekens et al.,
2020). The importance of coordinated rehabilitation approaches for
patients with PICS, as part of the COVID-19 rehabilitation pathways,
emphasises a multi-professional approach involving relevant health
professionals and service providers across sectors to support individuals,
families and carers (Smith et al., 2020).
Some reports are also highlighting other neurological consequences of COVID-19, such as Guillain-
Barre syndrome (Toscano et al., 2020, Zhao et al., 2020), stroke encephalitis, motor peripheral
neuropathy and demyelinating lesions (Butler et al., 2020). It is imperative that a thorough
neurological assessment is carried out during the rehabilitation of people post COVID-19.
It has been suggested by Prvu Bettger et al. (2020) that a core set of measures needs to be adopted
to monitor the health and functional outcomes for patients after COVID-19, as well as other patients at
risk of functional decline, in order to assess the quality, availability and accessibility of services today
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and as our nations recover (Prvu Bettger et al., 2020). This may assist in estimating the burden and
cost of disability related to COVID-19.
With COVID-19 only emerging in December 2019, it is still early in terms of tracking and identifying
longer term health effects and subsequent disability and consequences for individuals and services.
It is estimated that 15% of the world’s population live with disability, many of whom require
rehabilitation support, or interventions either in the acute phase after the initial onset of a disability, or
on an on-going but intermittent basis as required when living with a chronic condition.
WHO-Europe notes that ‘there is a substantial and ever-increasing unmet need for rehabilitation
worldwide which is particularly profound in low and middle income countries. This unmet need has
been exacerbated by the pandemic with many services shutting down to reduce the spread of the
virus and due to a lack of human resources, particularly in places that previously had sparse service
provision and poor access. WHO/Europe is developing guidance to support and advise rehabilitation
professionals throughout the pandemic’ (World Health Organization Regional Office for Europe,
2020).
The NCD Alliance has also drawn attention to the impact of COVID-19 for people living with non-
communicable diseases (NCDs). (NCD Alliance, 2020) A significant population who are supported by
long term physiotherapy and rehabilitation services and a population at particular risk of severe
complications from COVID-19.
As many countries in the world are in lockdown, large numbers of people living with a disability will not
have been able to access services, or will have had to access them in a different way, such as online
via telerehabilitation platforms. However, many people will have been left behind, particularly
vulnerable groups with no voice, or those in lower resource settings for whom access was a challenge
even before COVID-19. Rehabilitation services are an essential component of high-value care
offered for individuals across the lifespan, to optimize physical and cognitive functioning and to reduce
disability. They should continue during the pandemic, acknowledging that there are various
implications for different patient groups as well as health service delivery and the infection risk needs
to be considered and managed (Pan American Health Organization, 2020, Prvu Bettger et al., 2020).
WCPT agrees with this noting that a lack of access to physiotherapy services can compromise health
outcomes, extend inpatient stays and result in preventable hospital admissions.
Frail older people are at risk of many of the same issues as those living with a disability and their
needs must be addressed. With most lockdown strategies requiring older people to stay at home and
self-isolate there is concern for both the short term and longer term needs of this population (Armitage
and Nellums, 2020, Lloyd-Sherlock et al., 2020, Petretto and Pili, 2020). This will be explored further
in the next rehabilitation briefing paper WCPT will be producing.
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People with short-term rehabilitation needs where
routine care has been suspended
Rehabilitation services need to continue during a pandemic, as they are an essential component of
high-value care offered for individuals across the lifespan to optimise physical and cognitive
functioning to reduce disability. Physiotherapy, as a health profession, has a critical role to play in
maintaining the health and wellbeing of the community. However, with many physiotherapy services
suspended during the period of social distancing, patients will likely experience a deterioration of
other conditions unrelated to the COVID-19.
Changing priorities to service delivery have impacted across widespread areas where
physiotherapists provide rehabilitation:
elective surgery has been cancelled in the midst of the COVID-19, hence there will be many
people who have become deconditioned while they wait for orthopaedic and other surgeries
individuals with acute musculoskeletal problems may not have been able to access
physiotherapy
individuals, unable to leave their homes for several weeks, will become even more sedentary,
lose mobility and function, and require physiotherapy services when restrictions are lifted
The long term effect of delays in accessing and seeking physiotherapy services, or in doing little
physical activity while waiting for surgery, could have devastating effects on the overall mental and
physical health of a person. This may lead to more disability, which will require more rehabilitation, but
the funds for this are likely to be prioritised elsewhere, leading to a downward spiral for the individual,
their family and society.
However, there is now an opportunity to prevent this community-wide functional decline in certain
settings. Telerehabilitation is an important tool in allowing physiotherapists to rise to the challenge of
this unprecedented situation and prevent functional decline. To prevent a public health emergency in
the months ahead governments should allow physiotherapists to deliver telehealth services with
appropriate reimbursement, where relevant. WCPT is aware that this was already permissible in some
countries, others have responded rapidly by implementing changes to professional regulation and
insurance reimbursement mechanisms in the face of the pandemic. In some instances, this is
reportedly a temporary measure, but WCPT advocates for the professional autonomy to be creative
and responsive in delivering services to meet needs.
A recent survey of its member organisations by the International Private Physical Therapy Association
(IPPTA), a WCPT subgroup, noted that in countries where telehealth is permissible, in two-thirds of
cases this availability has been recent and in response to COVID-19. However, this approval was only
temporary in 43% of cases (see
https://www.wcpt.org/sites/wcpt.org/files/files/wcptnews/IPPTA_Telehealth_Survey2020.pdf).
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Rehabilitation with public health restrictions
While rehabilitation for certain people may be appropriate via telerehabilitation platforms, for some this
will not be possible or appropriate.
Once lockdown eases and services can resume they may do so in a different environment, depending
on the public health recommendations implemented. This will relate to infection prevention and control
requirements and ongoing physical distancing needs. These may apply for all people in the
community or for defined vulnerable groups.
Consideration will need to be given to how rehabilitation services will return and be managed as
restrictions are adjusted and begin to be lifted. How will inclusive rehabilitation emerge that will limit
the impact of public health restrictions, as well as other disparities that will be heightened such as the
digital divide and social determinants of health and wellbeing? There is a risk that some individuals,
previously in the system, may be missed having become disconnected with services. Service
providers will need to review priorities and may need to implement triage and outreach strategies to
get services up and running again.
The consequences of widespread ‘lockdown’ has resulted in much of the world’s workforce being
obliged to work from home, being furloughed (temporary layoff from work with or without financial
support) or losing employment.
There are a number of key aspects to be considered when people will return to work; for example,
ensuring people are fit to return to physically demanding work, those with disabilities being supported
with staged returns, working environment changes that arise from physical distancing and the impact
on individuals and the work that they do.
The International Federation of Physical Therapists working in Occupational Health and Ergonomics
(IFPTOHE), a WCPT subgroup, is preparing resources for considering the potential rehabilitation
needs for these people. Details will be added to the WCPT COVID-19 website information hub when
available.
Physiotherapists themselves will also be embracing a different practice environment and will need to
ensure they are adequately supported to provide their services. Access to appropriate personal
protective equipment (PPE) is likely to play an ongoing role in this. WCPT’s #PPE4PT advocacy
campaign will continue to be important as services re-emerge.
Whilst the focus may be on physical ability and the return to work, the potential impact on mental
wellbeing for all affected should not be neglected.
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Changing service delivery and workforce
implications
To date we have seen significant changes in the physiotherapy workforce and these will be ongoing
and varied as they respond, adapt and proactively change in response to the changing environment
and rehabilitation needs.
Physiotherapists are integral to multi-professional teams in delivering coordinated rehabilitation and in
working in cross-sector partnerships to bridge settings and service delivery providers.
Health services rapidly responded to the need to address the immediate acute phase of the
pandemic. As demands on acute services reduce attention must be given to the needs of patients
post COVID-19 and the wider population with non-COVID related rehabilitation needs.
Service capacity across the continuum of care will likely need to respond to changing priorities, surges
in demand and potential future acute phase waves.
During these times and for the foreseeable future, the mental, physical and emotional stresses on
physiotherapists and all frontline health workers should not be underestimated and appropriate
services made available to ensure the wellbeing of staff (Walton et al.).
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